Amputees pushing for more coverage

Almost two years ago Ken Dickinson, of Ooltewah, lost the bottom half of his left leg in a motorcycle accident.

For six months he and his prosthetist were locked in a battle with his insurer to get coverage for a new prosthesis.

His insurer, United Healthcare, deemed a replacement “not medically necessary.” After months of repeated appeals, United finally agreed to pay $2,500, the most the insurer will reimburse for prosthetic devices.

Mr. Dickinson said his prosthetist at the Amputee Clinic on Shallowford Road absorbed the balance of the $20,000 cost for the device.

“All I want to do is just be able to get up go to work, do some things around the house,” he said. “I’m not trying to play basketball. I just want to be able to function.”

United declined to comment, said Roger Rollman, a spokesman for the insurer’s Southeast region.

For amputees and their prosthetists here and nationwide, the struggle for prosthetic coverage is becoming more common.

Facing cuts to private insurance coverage for prosthetics, amputees and advocates in Tennessee are pushing state legislation to mandate coverage, while insurers protest that such requirements will increase premium costs for the privately insured.

Tennessee’s proposed legislation is part of a national effort to mandate prosthesis coverage in the face of diminishing benefits, Morgan Sheets, national advocacy director for the Knoxville-based Amputee Coalition of America, said.

Laws mandating coverage have been passed in nine states, and legislation is on the table in 31 others. Many of the laws require that insurers pay on par with Medicare, which covers at least 80 percent of prosthesis claims and usually provides replacements every three to five years.

The bill likely will be heard in the state House industrial impact subcommittee in the next few weeks, said subcommittee vice chairman Rep. Richard Montgomery, R-Sevierville. He said the bill will have a small chance of passing if it raises costs for the state, considering this year’s projected revenue shortfall of about $180 million.

“No question it’s an important piece of legislation that’s got to be addressed, but you’ve got to make choices, and I don’t think that’s one that will be made this year,” he said.

The bill was killed last year after the state protested that its requirement for health plans to pay at least on par with Medicare would raise costs to TennCare.

TennCare, the state’s managed Medicaid program, reimburses at a rate of about 33 percent less than Medicare, said Marilyn Wilson, spokeswoman for the TennCare Bureau. But, she said, “if a doctor says a patient needs it, it is covered.”

Sponsors of the bill are amending the legislation this year to seek only at minimum what TennCare provides, so as not to add any cost to the state budget and still provide an adequate level of coverage to amputees, Mike Alder, a lobbyist on behalf of the bill, said.

COVERAGE LIMITS

Amputees with private insurance face $1,000 or $2,500 caps on coverage for their devices, or limits of one prosthetic per lifetime, said Michael Fillauer, president of Fillauer LLC, an orthotic and prosthetic device manufacturer on Amnicola Highway.

“It is incredibly ridiculous,” said Mr. Fillauer. “It’s like having one pair of shoes per lifetime policy.”

Mr. Fillauer heads a campaign in Tennessee to require private insurers to pay for at least what TennCare pays for prosthetics, as well as cover repair or replacement of a device.

Basic prosthetic devices can cost between $3,000 and $12,000, sometimes more, and state-of-the-art models can cost tens of thousands of dollars.

For growing children and amputees whose residual limbs change, a limit of one prosthesis per lifetime is unreasonable, Mr. Fillauer said.

Insurers often categorize prosthetics with their durable medical equipment benefit, Ms. Sheets said. Outside prosthetic and orthotic devices, durable medical equipment tends to be low cost, such as canes, crutches and walkers. For those needs, a $2,500 cap is no problem.

Most people often don’t think to consider the constraints that cap puts on prosthetic needs, Mr. Fillauer said.

“People don’t expect to be an amputee,” he said.

BlueCross BlueShield of Tennessee opposes mandates for coverage, which have been shown to raise costs in premiums for the privately insured, said Mary Thompson, spokeswoman for BlueCross.

The company does not have caps on prosthetic coverage, she said.

Protecting prosthetic coverage ultimately will save public money and only will add about a dollar a year to premiums for privately insured individuals, supporters of the legislation said.

Denying access to prosthetics can make an otherwise healthy and productive member of society dependent on government programs or the health care system for survival, Mr. Fillauer said. Some amputees are compelled to quit their jobs to qualify for Medicaid and receive prosthesis coverage, and those who can’t get a prosthesis often end up with other health problems, such as obesity and depression, he said.

BUSINESS, PERSONAL COSTS

Prosthetists increasingly are absorbing the cost of care for patients who cannot afford their care out-of-pocket, putting some businesses in financial jeopardy.

“It’s killing us,” said Marcum Randall, prosthetist and owner of the Amputee Clinic. He said he provided 30 patients with free care last year because of insurance coverage issues. “We’re just not getting paid.”

Melanie Stubbs, co-owner of Stubbs Prosthetics & Orthotics Inc. in Chattanooga, said the company faces the same problem.

“I anticipate that in the future we’re going to find ourselves having to put off services for an amputee and possibly even turn an amputee away, and that’s something we’ve never done,” she said.

Chattanooga resident Frances Ledford, 25, has had a prosthesis all her life due to a birth defect and runs a support group for amputees here. She has heard stories of denials of prosthetics claims more and more in recent years.

“Now they’re denying things that are essential to be able to walk, saying it’s not a medical necessity. How can it not be medically necessary for me to walk?” she said. “Just like a diabetic that needs insulin, we need these prostheses to be able to function. If we can’t function, it means we can’t work and it means we have to live off the government.”

TENNESSEE’S PROSTHESIS LEGISLATION

House Bill 2145, co-sponsored by state Rep. Frank Niceley, R-Knoxville, and Sen. Tommy Kilby, D-Wartburg, would require insurers to offer coverage that covers at minimum what TennCare pays for prosthetics as well as repair or replacement of a device if called for by the patient’s doctor. Insurers could require preauthorizations.